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EP on EP Episode 91: Return to Sports (Part 1) wit ...
EP on EP Episode 91: Return to Sports (Part 1) wit ...
EP on EP Episode 91: Return to Sports (Part 1) with Michael J. Ackerman, MD, PhD
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Video Transcription
Hi, this is Eric Prostowski, and welcome to another segment of EP on EP. It's an absolute delight to have a former guest with us again, Dr. Michael Ackerman, who is a genetic cardiologist at the Mayo Clinic, and of course, that's underplaying his international role in our field and in the field of molecular diseases. So Michael, welcome back to the show. It's great to be with you again, Eric. And I mentioned earlier, I see you have your Baylor National Championship in the background. And it sounds like you're proud of the team. Very proud. And it's where my third son went to school as well. So congratulations on the championship. So let's get into the interview. You know, there's so many different areas we could discuss, but you've written some very nice papers recently about this concept of return to play in athletes who have some of these genetic abnormalities, and in particular, maybe we can concentrate on Long QT syndrome. Why don't you start by telling us, actually, why do they get sidelined to begin with? Yeah, well, I think they get sidelined because that has essentially been the law of the land for two, three decades. It sort of has been, if in doubt, kick them out. So when I joined the faculty of Mayo Clinic in 2000, it just never made sense to me as to why is that the way we do it? Is that the best we can do for these athletes with a whole variety of genetic heart conditions? And we focus particularly on Long QT syndrome, and it just seemed like there had to be a better way. You know, the various guidelines in the past, Bethesda 26, Bethesda the next, they all sort of said, unless your heart is perfect, you're done. You're done with your competitive sport of choice, and maybe we'll give you a couple to choose from, like cricket, but basically, you're done. And I just felt that that was fundamentally wrong in terms of principal decision making that why could we not do shared decision making for this complicated and complex topic? And so we started to see these athletes and these patients in light of not an immediate de facto shutdown, but how now shall we live, and can we still live and thrive despite your diagnosis? Well, that's a great intro, but you can't guess in this area, right? So you had to go through, I'm sure, years of a thought process program to be able to have that shared decision making with the patient. And I know it's been a couple of decades, but can you capsulize it for us in sort of what you found out in your many years of researching this area? Yeah, I think what we found out is, so I've seen over 4,000 patients in Mayo Clinic's Wendland Smith Rice Genetic Heart Rhythm Clinic. They're not all athletes. In fact, most are not, they're just ordinary humans, but over 700 athletes have been under my watch over these last 20 years, over 500 with long QT syndrome itself who have returned to play. And I think some of the things we learned very early on was first, we debunked a myth that's been out there for a long time, which has said, if we let the athlete and his or her parents decide, they'll always choose to stay in sport, they cannot self-disqualify. And that's absolutely not true. 10 to 15% of every athlete who we've seen, who have flown to us specifically to get reinstated, they've disqualified themselves as a family unit after the evaluation. So I think that myth has been debunked. And then I think the second thing we've learned is, yes, sports may be long QT irritating as your portal of entry. In other words, that's how you got found out that you have long QT. But once you're diagnosed, risk stratified and treated, then maybe those risks have been neutralized. And we certainly have seen it from a practical standpoint of when we've permitted a return to play for an athlete with long QT syndrome, their event rate has been incredibly low. And over the last 20 years, their lethal event rate has been zero for 20 years and counting for 500 plus athletes, 1500 plus athlete years of observation. So I think we've seen that when we treat them well, evaluate them well, counsel them well, that they can safely return to play in most scenarios for most sports very comfortably. So let's dig into that a little more detail because you haven't mentioned, for example, the genetics of it. Can you educate us on, is there a particular long QT type that you might say, no way, you can't go back or I'm really worried? Does that come into your decision? Yeah, beautifully, no, not after you've been treated. And that's been the beauty of it is that you're right, there are many different flavors of long QT syndrome genetically. There's the three big ones, LQT1, 2, and 3. And we certainly know that LQT1, when you're untreated and undiagnosed, that has a tendency to declare itself during adrenaline, during exercise, during sports, during swimming. There's the strong link for swimming, whereas LQT2, maybe when the gun goes off to start the race, but not during the a hundred meter dash, that would be LQT1. But most of our patients who have returned to play are LQT1. So over half of all of the patients who are in our return to play cohort, in fact, have the very genetic version of long QT, where there's a predilection for events during sport, but that's again, before you were diagnosed, evaluated and treated. And so no, we have even LQT1 swimmers, Olympic level swimmers. So again, I'm not really afraid of those scenarios that bring you to attention when you have not yet been diagnosed. I think once we are diagnosed, we can neutralize the threat of that previous activity almost completely. Well, let me again, I'm going to ask you questions like I would if you were giving me a lecture, which you have done in the past and are like, what's my next question for you? And that would be, well, you're going to give them a beta blocker for sure. That's my guess. And my experience giving beta blockers to high level athletes has not been very good. Most of them really don't like it. So how have you dealt with that issue? Yes, so we tailor therapy, not exclusively because they're an athlete, but you're right. The primary therapy for most athletes and non-athletes with long QT syndrome is just plain old beta blocker. Natalol being the beta blocker of choice. Many patients tolerate the beta blocker, but you're right, many don't. And whether you're an athlete or an artist, if you hate life on beta blocker, we can do different and probably the biggest different that's well in place now at certainly destination centers like ours is left cardiac sympathetic denervation surgery. That treatment modality has really taken center stage for two scenarios in long QT. Bad disease, the fibrillator keeps going off. What should we do? Denervation. Not so bad disease, but bad therapy, as in I hate life on beta blocker. What could we do? Denervation. And so not surprisingly, some athletes, particularly those with sports where the engine needs to be running at high, high level, they choose denervation because they hate beta blocker. But there are other athletes where they might even suggest that their beta blocker has made them a better athlete. So it kind of depends on what the sport is, what the position is, what the call on the engine is, if you will. But innovation certainly has an important, important place in the treatment of long QT, whether you're an athlete or not an athlete. And help help me decide the dosing. So I know with the dosing I use routinely, do you do you change how you approach it? Because these are high level athletes and it may impair their athletic ability. What what what do you use for your endpoint in your beta blocker dosing in a high level athlete? Yeah, great question. I think it's a combination thing. First, it starts with what do I assume or have deduced as the declared risk? So do I put them in sort of low, medium, high risk bucket? If they're very, very low risk, I'm not trying to get to one milligram per kilogram per day of natal law. If they're spooky risk, yeah, I absolutely need to try to get the dose to one to that level or higher. But then I sort of titrate to side effect. When do we hit the wall and when do they no longer like you and me? Because we made them daily miserable instead of on side effect free. And then once we reach sort of their maximum acceptably tolerated dose, I call it. Can I see a measurable effect on their stress test to know that I physiologically have gotten beta blocker into the system to where I decrease the motor? And that's assessed by what level of reduction in peak heart rate have I achieved just as a way to know that there's a measurable circulating level of beta blocker in the mix that they're telling me is their maximum acceptably tolerated dose. So it's a combination of those factors. Thanks, Mike. So let's talk about the ICD or the person, for example, that comes to you, wants to play sports, who's had an event. Let's say something that's clear cut. Cardiac sync could be by your judgment. Maybe they haven't gotten an ICD yet. You would treat them with beta blockers, I presume. Do you treat the athlete, though, that has had an event, especially one with an ICD differently? And I understand this is complex because part of it is your decision and part of it is actually could be the school's decision. Right. I mean, so how do you handle that? Yeah, I think it depends by symptomatic long QT syndrome. So whether you're an athlete or not, I don't really care. I don't give you a defibrillator quicker because you're an athlete to enable you to return to the field. I think that's a slippery slope. That's probably dangerous. In other words, having some cardiologists who would say, I don't think you need a defibrillator, but I'm not going to let you return to that sport or sign off on your form unless we install a defibrillator. I don't like that. I think that's wrong. I think that's dangerous. But let's say you're a long QT athlete and you did cardiac arrest to where all of us or almost all of us would give you a secondary prevention ICD. I think returning to your sport in that setting is still very possible. And we just published, you know, we published our athlete experience, 20 year experience in Jack last year. And we just published the subset analysis this month in Mayo Clinic proceedings comparing those athletes with long QT syndrome under my watch who have a defibrillator compared to those who don't. And the majority don't. So 85% of my athletes are athletes without an ICD. And when we look at the 15% of the athletes with an ICD, of course, they've had more events when they've returned to sport or returned to life because there was a reason they got their defibrillator. But what we show is that is that there still have been zero deaths. There have been shocks, appropriate shocks, either during sport or when they were brushing their teeth. And that that has range. If we look at all comers, if we look at the athletes with defibrillators who have long QT, their event rate is about seven per 100 athlete years. If we look at the majority of the athletes with long QT syndrome who don't yet own a defibrillator and probably never will, their annual event rate is 0.2 per 100 years. In other words, I think we're getting pretty good at figuring out who does and does not need a defibrillator. But even for those who need a defibrillator, we can keep them in the game of life in most situations. Well, let's go to the I know we don't have too much time left, but sometimes the issue I mean, I'm assuming you're going to do what you've talked about. You'll do your shared decision making with the patient and maybe the family. But then comes either the professional sports team or the university. And I've had experience with both, as I know you must routinely. How do you deal with that, too? I mean, because that's really a different issue, right? You've located with with the provision that they understand the risks that they're taking. Yeah. How do you deal with the other? That's hugely important because if and I don't think we're doing very well for our athletes with them to prep them for the journey that's ahead of them, that our shared return to play decision making exercise that we might do doesn't matter almost at all at the division one university and the professional level. And I think we have to prepare the athlete and their family when they transition from varsity level high school sport to beyond. So, for example, my batting average to get an athlete back to his or her sport at the D2, D3 college varsity high school level or below is almost 100 percent. At the division one university athlete level and above, it's 50 50, meaning that university, that professional organization, that team says, I don't really care who this Ackerman is at this place called Mayo Clinic not playing here. And if we don't prep them well, we have these athletes who are getting full ride scholarships because they got recruited by a coach only to have the scholarship kept in place, but them disqualified after they get on campus and they run it up the division one university poll and the team physician or the university lawyer says not here. And so we have to prepare the families that what we call shared decision making ends at that professional or near professional level. And I've called it either TDM for their decision making or BDM, which is probably better, which is business decision making model. And they just have to be readied and we can advocate for them, make ourselves readily available to speak to the team physicians and the and all of the individuals. And I do that a lot, but. It ultimately is a business decision making model and they just need to go in that athlete and their family needs to go into that transition from high school to college and beyond with eyes wide open. Well, Mike, this has been a fabulous discussion. I can't thank you enough for the research you've done over the years and the education you gave us today to this gnarly problem. Thanks. Thanks a bunch for being part of the show again. Well, thanks so much for having me and I can't wait to do it again with you sometime.
Video Summary
In this segment of EP on EP, Dr. Michael Ackerman, a genetic cardiologist at the Mayo Clinic, discusses the concept of return to play in athletes with genetic heart conditions, specifically focusing on Long QT syndrome. Traditionally, athletes with this condition have been sidelined due to the perceived risk of sudden cardiac events. However, Dr. Ackerman argues that a better approach is needed and that shared decision making should be used to assess the individual risks and benefits for each athlete. He shares his experience of treating over 500 athletes with Long QT syndrome who have returned to play with minimal event rates. Dr. Ackerman also discusses the use of beta blockers as the primary therapy for most athletes with Long QT syndrome, as well as the alternative option of left cardiac sympathetic denervation surgery for those who cannot tolerate beta blockers. He also highlights the importance of preparing athletes and their families for the different decision-making models used at the professional and university levels. Overall, Dr. Ackerman emphasizes the need for individualized and informed decision making to allow athletes with genetic heart conditions to safely participate in sports.
Keywords
Long QT syndrome
return to play
shared decision making
beta blockers
genetic heart conditions
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